Provider Demographics
NPI:1093162620
Name:YOURTHERAPISTOFFICE
Entity Type:Organization
Organization Name:YOURTHERAPISTOFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-489-7384
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-0312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7519
Practice Address - Country:US
Practice Address - Phone:678-489-7384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management